EVENTS

Well, I Can’t Really Get Boners, But…

… I’m still just as excited as Crommunist apparently is about the recent results of a study conducted in Vancouver on the efficacy of prescribing heroin as part of clinical treatment for addiction.

So… here’s the story: there was this little pilot project conducted here in Vancouver, in my beloved Downtown Eastside (home to one of the worst heroin epidemics, and some of the worst urban blight, in the developed world) called NAOMI. The idea is prescribing heroin (diacetylmorphine) to addicts, and providing it to them free of cost, as part of either a harm reduction or treatment plan. NAOMI was run out of a little corner store on East Hastings to a select trial group of patients recommended through other clinics (presumably patients for whom other treatments such as methadone or in-patient detox were ineffective).

The harm reduction aspect of the project was fairly straightforward. First of all, the heroin being distributed would be safe and controlled for potentially dangerous additives. Patients’ use could be regulated and monitored. Patients would not need to purchase their drugs with their welfare money (which is proportioned based on the assumed minimum one requires to pay for necessities such as shelter, food and toiletries) and thus be better able to afford basic necessities, which carries innumerable health benefits. Patients would not need to steal, engage in sex work, or turn to other forms of crime in order to finance their addictions. And in the event that such a project were instituted on a large scale, it would deal a significant financial blow to the dealers, gangs and smuggling rings that meet the demand for heroin. Between the effect on organized crime and petty street crime, it would have an immense impact on crime reduction.

The treatment part is where things get interesting, and where this study has produced singularly important (and potentially paradigm-shifting) results. What NAOMI found was that prescribing heroin, rather than heroin substitutes such as methadone or buprenorphine, actually produces better results in terms of ultimately achieving abstinence. I understand your incredulity, so here’s a link to the original article. This is primarily due to a significant decrease in drop-out rates from the treatment program. Methadone is all well and good, but if dissatisfaction with its ability to manage cravings ultimately leads the recovering addict to relapse, the whole thing was pointless. But doling out gradually decreasing doses of heroin will give patients far more incentive to remain in the program, and keep them “hooked in” to the treatment plan rather than simply giving up. Of course, a genuine desire to ultimately get clean would be required for treatment to be effective, but this is true in the case of any addiction treatment.

The idea of keeping addicts “hooked in” to the healthcare system is also of pivotal importance in general. Social programs designed to address social issues, provide assistance, reduce harm and produce overall community benefits only work in so far as those targeted are aware of those programs, interested in the programs, able to access them, and willing to access them. This is one of the subtler, but just as important, benefits of projects like InSite, Vancouver’s safe injection site. In addition to the immediate benefits such as keeping needles off the street, preventing overdose, reducing transmission of blood-borne pathogens and so on, having a sort of bridge between the street-level addicts and homeless and the social projects that can help them is of vital importance. In addition to sterile rigs and a safe place to shoot up, InSite provides information and access.

A NAOMI-like project would have similar benefits. Rather than addicts simply being derelict and off the grid, they’d be participating in the healthcare system, where they could be provided direct access to doctors, social workers, help with getting income assistance or disability benefits, help finding treatment for whatever health issues they may have (mental health issues, dental hygiene, treatment for HIV, treatment for infections, abscesses, etc.) and all kinds of other things.

The long term cost and benefit analysis is very important here too, though. In terms of the potential increase in beneficial outcomes for treatment, treating addicts with heroin and keeping them in the program (even if it doesn’t always lead to abstinence, but instead a maintenance / harm-reduction model) will save an enormous amount of money in terms of treating the health problems associated with falling out of treatment programs and back onto the street. Simply keeping addicts in the care of doctors, using safe and controlled heroin, has immense potential in terms of preventative medicine, and avoiding complications that lead not only to considerable and prolonged suffering on the part of the patient, but also to considerable expenditures on the part of the health system.

When you take the amount of money that would be saved in terms of not having to treat preventable complications from patient drop-outs and poor outcomes, and compound it with the amount of money in property losses and police-spending that would be saved by the widespread reduction in drug-related crime, and you have incredible financial benefit acting as an incentive in addition to how well such a model would be more compassionate and better help the patients themselves.

NAOMI comes out, once again, proving that the actual medical evidence falls overwhelmingly on the side of harm reduction and moving past our long-since-proven-useless punitive and moralistic models for drug policy. This excites me, because we have yet another trump card in our already staggering winning hand in terms of arguing that progressive drug policy is clearly the one supported by all the real-world evidence.

Though ever the cynic, I worry about the fact that we already have a staggering degree of evidence supporting harm-reduction and progressive drug policy. We already know they’re more effective than what we’ve been doing. But the Harm-Reduction, Prevention and Treatment “pillars” are all still pitifully underfunded in comparison to the runaway juggernaut of Enforcement. And so much time and energy has been spent rendering drugs a moral issue, so much was invested in the strategy of stigmatizing them in the misplaced hope of deterrence, so much of our cultural attitudes and public institutions are based around the assumption that we must must must not under any circumstances tolerate or “enable” addiction (even if it’s obviously the best and right to do!).

And directly giving heroin to heroin addicts? That runs direct against the grain of received wisdom. It would require either being done very, very quietly (hopefully without our southern neighbours noticing and sticking their noses into it), or totally undoing a century’s worth of cultural conditioning, and while we’re at it admitting that the powers that be were not only wrong, but totally, completely wrong. It would require admitting, collectively, as a nation, that we’ve spent the last 70 years taking exactly the wrong approach to the problem of drug use and addiction. It would require admitting to one of the biggest fuck-ups in the history of policy-making.

Ever noticed how rare it is to even notice one person in an internet comment thread admit they had something wrong? Yeah.

So, I hate to kill a policy boner, or give Crommunist policy blue balls, but I’m just not all that optimistic about the potential for this to make it to policy. Especially with Harper still Prime Minister. And his robocall-ensured majority parliament and “mandate”. And C-10 around the corner. And all the new prisons he wants to build.

I just hope the whole “that wasn’t actually a democratic election” scandal can lead to a vote of no-confidence. Then, MAYBE, we’ll see things like some steps forward in terms of drug policy. You know… policy actually based on evidence.

Comments

Another great post. I’ve argued for a long time that all drugs should be decriminalized and that the “War on Drugs” needs to end. Criminalizing and imprisoning drug users is a completely absurd policy that has caused more harm and suffering to an already-vulnerable population, and has made the drug trade even more dangerous.

But while I support outright legalization of marijuana, I’ve been unsure as to what approach should ideally be taken with hard drugs like heroin. Based on this evidence, it sounds like the Vancouver harm-reduction model is pretty effective, and should be adopted more widely.

(As you point out, it’s getting the politicians to accept it that’s the hard part.)

So, I hate to kill a policy boner, or give Crommunist policy blue balls, but I’m just not all that optimistic about the potential for this to make it policy. Especially with Harper still Prime Minister. And his robocall-ensured majority parliament and “mandate”. And C-10 around the corner. And all the new prisons he wants to build.

Vancouver and BC have repeatedly demonstrated that they can’t find two fucks to rub together when it comes to Ottawa’s war on drugs. My optimism isn’t blind – I look at Insite, I look at the Amsterdam Cafe, I look at Jim Chu (VPD chief) and I think that we may yet see the city and province flex some of their muscle to get better health/economic outcomes.

Enrolment criteria for Vancouver:
Have been addicted to heroin, dilaudid or another opiate for five years;
Have been injecting opiates, primarily heroin, for the past year;
Have tried methadone programs more than once, or methadone and another treatment program;
Are 25 or older;
Are a resident of the Downtown Vancouver community and have been for an extended period of time.

There was another study in Montréal. I can’t read french but I assume the enrolment criteria were the same.

These are the results of a computer model based on the data from the North American Opiate Medication Initiative, which was finished in 2008 (as best I can figure). Main outcome measures were lifespan (over a 15-year period), time spent in treatment, time spent in relapse, a measure of life quality called QUALY (which I don’t like, but it’s what’s commonly used… *grumble*) and societal cost.

I’m sorry, but I think these results are weak. There are huge overlaps in confidence intervals, which I interpret as there being a large probability that the two methods are equally cost effective. It’s entirely possible that I’ve misunderstood something – this isn’t my field at all – so if other people with the proper background care to look into it, I would be very grateful. But I wouldn’t make too much of this study before it has been properly studied and commented upon by the scientific community.

Again, I’m sorry but that’s my impression of this study. And, as you pointed out, it’s not like the argument for harm reduction hinges on this study.

Can someone help me with table 1 in particular? It seems to indicate that someone on heroin was three times more likely to die than someone on methadon. That in and of itself makes me cautious about recommending this.

I’m a physicist so I have difficulties understanding there nomenclature, but what I take from table 1 is that the risk of death for Diacetylmorphine treatment is a lot higher than for the methadone treatment, but still a lot lower than unsupervised use. If you factor in that the chance for a relapse in the methadone group is a lot higher than for Diacetylmorphine, the overall treatment with deaths from relapses factored in might still favor Diacetylmorphine over Methadone.

So, spending a month on methadone has risk 1. Spending a month on diacetylmorphine has a risk of 3. And spending a month on the street has a risk of 10. So even though methadone is safer than diacetylmorphine, those on the methadone program will spend so much more time on the street that in the end it’s fairly much a wash.

The numbers shown are my estimations of the data in the paper. They are probably wrong but will give the right idea. Don’t show this to my statistics teacher. She will send her ninjas after me.

I hate to sound like a conspiracy nut, your article is excellent, but there is one important point that you are missing.
Current drug policy is based on evidence. You are mistaken about its real goals. The additional harm done by the drug policies and not the drugs themselves is by design and not by accident.
Drug policy since the very beginning has always been about outlawing people in the presence of a constitution that guarantees equality before the law.
If drugs open your mind to the possibility that you might be wrong (I think I’m paraphrasing Leary here) then it is a priority for a conservative government to ensure that the harm done to drug users is big enough to enforce conformity. Because by conservative definition the status quo is good but it was even better 10 years ago and novel ideas always threaten to make it even worse.
Criminalizing the poor – or Chinese Immigrants as was the historical reason for outlawing heroin – and keeping people afraid of the dangers of drug use, those are standard fear mongering tactics.
I’m not denying the inherent dangers of drugs, but alot of those dangers are the consequence of drug policy.
Given the evidence that the current policy actually increases the harm done, maybe there will be a change but I doubt it.
Considering the role of the USA in the war on drugs, and the prevalent puritan “pleasure is evil” culture in the US, I don’t think they will change their drug policy soon, and they will definitely try to continue forcing this policy on others.
This is eerily similar to the abortion debate, policing bodily autonomy actually increases the harm and yet people manage to phrase the issue as some kind of good vs. evil.
And in both cases it is not a real conspiracy but rather widespread and willful ignorance exploited by a few people who see it as an opportunity to enrich themselves.
Sorry for the long rant, I’m exaggerating of course but sometimes this is the impression I get.

The reasons for drug hysteria are complex, of course, but I think Chris Rock nailed one aspect. He said the reason alcohol is legal and pot is illegal is that alcohol makes white men rich, and pot doesn’t.

Great post. Thanks for informing me about this fascinating study. I’ve got the same reservations about the data that Anders discussed, but from what I can see I agree that this approach appears to out-perform Methodone in the long term.

Tangentially related: I remember once being told about a (UK?) study which found that over time heroin addicts will often come off the drug themselves. Does anyone know anything about that? Is there actually any data to support that hypothesis?

There was a similar project in my home town, and I remember reading about comparable results, http://www.heroinstudie.de/
but most of the publications are in German.
There is apparently also a Dutch project with several publications avaiable in English http://www.ccbh.nl/ENG/indexN4.htm but I did not have the time to read them yet.

this is a fascinating study… but like you, I’m also very skeptical about whether any amount of evidence is ever going to stop the War on Drugs; partially because, indeed, it is more part of the war on politically powerless people (part of maintaining the kyriarchy) than any attempt at lessening negative effects of addiction to illegal drugs.

Mm-hmm. But Crommunist has a good point. Vancouver has made a lot of headway. InSite (the safe injection site), NAOMI, “four pillars” approach, New Amsterdam Cafe (the marijuana cafe), the relative safety and stability of the grow-ops, legal medical marijuana (prescribed on a pretty loose basis… “anxiety”, etc.), the dispensaries, the effective decriminalization of marijuana possession, etc.

I think in the case of our fair city, on the one hand the social consequences of heroin got so bad (alleys in the DTES completely littered with used rigs, rates of HIV transmission comparable to Botswana, a couple dozen bodies in the coroner’s office every Welfare Wednesday, etc.) led to a situation of desperation where the necessity of coming up with some real solutions (however alternative) outweighed the political pressures from Ottawa and Washington, and on the other hand the cultural tolerance of marijuana, and cultural attitudes towards it, where the people in the city who used it (at least on a casual basis) far outweighed the number of people who opposed it in any real sense, while also the provincial economy was heavily bound up in marijuana production and export, and one of our primary cash-crops being forced underground created significant problems in terms of economics, tax expenditures and the police budget, and organized crime (if you ever get the chance, check out the show “Intelligence”, all about organized crime in Vancouver- which is actually a very interesting subject in real life. Our gangs and mobs have a lot of unique features). Those three conditions- the pressure to come up with solutions for the heroin / “hard drug” problems in the DTES, the socio-cultural attitudes towards marijuana, and the political, financial and criminal implications of marijuana playing a significant role in our economy- pretty much FORCED Vancouver into the position of having to adapt beyond the “War On Drugs” model, no matter the overall politics of it. If we had continued participating earnestly in the “War On Drugs”, we would have been one of the worst casualties of that “war”. Even those with the most power and privilege in Vancouver and BC weren’t willing to have our city and province be thrown under the bus just to help maintain a primarily American-driven project to keep certain groups “in their place”.

The only thing I have an issue with is the argument of “Medical Marijuana”.

Look if something is medical then it’s on a prescription and the only people who should use it are those who are sick. Marijuana is bloody harmless. If it’s “medication” then so is “alcohol” and “caffeine” which I need to improve my “social lubrication” and “my alertness deprivation”.

We shouldn’t treat it as a medication. It’s not one. For the majority of people who want to use it, it is a fun recreational drug much like a red bull and vodka. You don’t need to be ill to use it and enjoy it. Obviously sensible rules apply. Drink and Drive = Smoke up and Drive too.

For those who use it as a medication? We have medicated forms like the new spray that’s coming out which provides an inhaled metered dose of THC much like an asthma inhaler. That should be on prescription because it’s a proper medication.

Needle Exchanges and the like work. At worst it provides addicts with clean needles…

At best it provides you access to addicts and an area where they can ask for help should they require it. Many do ask and many get out of their habit from the help provided.